NV Medicaid and NV Check Up Pharmacy Manual€¦ · CHECK UP PHARMACY MANUAL Effective February 23, 2018 . Updated: 02/23/2018 (pv02/20/2018) Page 2 of 31 ... NV Medicaid and NV Check

NEVADA MEDICAID AND NEVADA

CHECK UP PHARMACY MANUAL

Effective February 23, 2018

Updated: 02/23/2018 (pv02/20/2018) Page 2 of 31

Copyright© 2018 by OptumRx, Inc. All rights reserved.

This document is intended to be a helpful resource to OptumRx Pharmacies providing services to Nevada Medicaid and

Nevada Check Up recipients. A copy of this document is posted on the Nevada Medicaid website for ease of reference.

The manual is updated regularly with program changes. The most current version of the manual can be found by following

the links on the Nevada Medicaid website (https://www.medicaid.nv.gov).

Effective 02/23/2018 (previous version02/20/2018)

https://www.medicaid.nv.gov/


TABLE OF CONTENTS 1.0 Introduction ....................................................................................................................................................................... 5

1.1 Nevada Medicaid Provider Telephone Numbers ......................................................................................................... 5

1.2 State Policy ........................................................................................................................................................................... 5

1.3 NEVADA MEDICAID/OptumRx WebSite......................................................................................................................... 6

1.4 System Availability .............................................................................................................................................................. 6

2.0 Program Setup .................................................................................................................................................................. 6 2.1 Claim Submission ............................................................................................................................................................... 6

2.2 Timely Filing Limits ............................................................................................................................................................. 7

3.0 Program Requirements ................................................................................................................................................... 8 3.1 Dispensing Limits ................................................................................................................................................................ 8

3.2 Tamper-Resistant Prescriptions ...................................................................................................................................... 9

3.3 E-Prescribing ...................................................................................................................................................................... 10

3.4 Dispensing Practitioners ................................................................................................................................................. 10

3.5 Generic Substitution Policy ............................................................................................................................................ 11

3.6 Maximum Allowable Cost (MAC) List ........................................................................................................................... 11

3.7 Covered and Non-Covered Drugs ................................................................................................................................. 12

3.8 Covered OTC Drugs .......................................................................................................................................................... 12

3.9 Recipient Co-Pay Information ........................................................................................................................................ 13

3.10 Prior Authorization Procedures and Diagnosis Codes ........................................................................................... 13

3.11 The Preferred Drug List ................................................................................................................................................... 14

3.12 Emergency Supply Policy ............................................................................................................................................... 14

3.13 Coordination of Benefits ................................................................................................................................................. 14

3.14 Medicare Part D Plan (PDP) and Dual-eligible Recipients ...................................................................................... 18

3.15 Gender Identity Disorder Hormones............................................................................................................................. 19

3.16 Family Planning Drugs ..................................................................................................................................................... 19

3.17 Hospice Drugs .................................................................................................................................................................... 19

3.18 Long-Term Care Claims ................................................................................................................................................... 19

3.19 340B Drug Discount Program ........................................................................................................................................ 20

3.20 Special Recipient Conditions (“Locked-in” Patients) .............................................................................................. 21

3.21 Compounds ......................................................................................................................................................................... 21

3.22 Partial Fill Functionality ................................................................................................................................................... 23

3.23 Injectable Drugs ................................................................................................................................................................. 24

3.24 Refills .................................................................................................................................................................................... 24

3.25 Vacation Fill ........................................................................................................................................................................ 24

3.26 Reason For Service Code (Conflict Code) .................................................................................................................. 24

3.27 Lost Medication .................................................................................................................................................................. 24

3.28 Use of Pharmacy Drug Discount Cards by Recipients and Retro-Eligible Refunds ........................................ 25

4.0 Prospective Drug Utilization Review (ProDUR) ......................................................................................................... 25 4.1 Therapeutic and Clinical Edits ....................................................................................................................................... 26

4.2 Call Centers ......................................................................................................................................................................... 27

4.3 ProDUR Alert/Error Messages........................................................................................................................................ 27

5.0 Provider Reimbursement .............................................................................................................................................. 28


5.1 Switching Fees ................................................................................................................................................................... 28

5.2 Ambulatory/LTC Network Pharmacy Payment Algorithms .................................................................................... 28

5.3 Ambulatory/LTC Network Pharmacy Dispensing Fees ........................................................................................... 29

5.4 Pharmacist Administered Immunizations ................................................................................................................... 29

6.0 Provider Education ......................................................................................................................................................... 30 7.0 APPENDICES TO THIS MANUAL ................................................................................................................................. 31


1.0 INTRODUCTION

Effective January 1, 2012, the Point-of-Sale (POS) system required pharmacies to submit claims to OptumRx

electronically in the National Council for Prescription Drug Programs (NCPDP) standardized Version 5.1 or Version D.0;

lower versions would not be accepted. Effective April 1, 2012, NCPDP Version D.0 is the only version accepted. After

submission, OptumRx will respond to the pharmacy provider with information regarding recipient eligibility, Nevada

Medicaid allowed amount, applicable Prospective Drug Utilization Review (ProDUR) messages, and applicable Rejection

messages. ProDUR messages will be returned in the DUR response fields; other important related information will be

displayed in the free form message area. It is extremely important that pharmacies display all messages exactly as

returned by OptumRx.

All arrangements with switching companies should be handled directly by the pharmacy with their preferred switching

company. Pharmacies must submit claims within 90 days of the date of service.

1.1 NEVADA MEDICAID PROVIDER TELEPHONE NUMBERS

Responsibility Phone Numbers Availability

OptumRx Technical Call

Center (Pharmacy Help

Desk)

866-244-8554 24/7/365

OptumRx Clinical Call

Center (Prior

Authorizations)

855-455-3311

855-455-3303 (fax)

24/7/365

1.2 STATE POLICY

Nevada Medicaid State policy is in Chapter 1200 of the Medicaid Services Manual (MSM). The MSM is on the Division of

Health Care Financing and Policy (DHCFP) website at http://dhcfp.nv.gov

http://dhcfp.nv.gov/


1.3 NEVADA MEDICAID/OPTUMRX WEBSITE

Announcements, meeting dates and policy updates are posted to the Nevada Medicaid/OptumRx website as they become

available. It is recommended that users visit https://www.medicaid.nv.gov weekly to view the latest information.

Pharmacy information is under the “Pharmacy” menu.

1.4 SYSTEM AVAILABILITY

The POS system is available 24 hours per day 7 days a week 365 days per year except during scheduled routine

maintenance. In the rare instance the POS system is down for any reason, hold your claims until online capability

resumes. Announcements will be posted at https://www.medicaid.nv.gov when the POS system is not available outside of

scheduled maintenance.

2.0 PROGRAM SETUP

2.1 CLAIM SUBMISSION

NCPDP version 5.1 format was accepted for all POS submissions through March 31, 2012.

NCPDP version D.0 format was accepted for all POS submissions beginning January 1, 2012.

NCPDP version D.0 format is the only accepted format for all POS submissions beginning April 1, 2012.

No other POS claim submission formats are accepted.

The following list provides important identification numbers for this program:

ANSI BIN # 001553

Processor Control # NVM

Provider ID # National Provider Identifier

Cardholder ID # NV Medicaid Pharmacy ID Number or SSN

Prescriber ID # National Provider Identifier

Product Code National Drug Code (NDC)




A group number is not needed for a Nevada Medicaid transaction.

The Nevada Medicaid Pharmacy card will list the recipient’s ID number, name and date of birth.

This recipient information must be entered exactly as it appears on the card (including any hyphens, apostrophes, etc.)

A middle initial is not mandated.

2.2 TIMELY FILING LIMITS

Most pharmacies submit point-of-sale claims at the time of dispensing; however there may be extenuating circumstances

that require a claim to be submitted after being dispensed.

For all original claims and adjustments, the timely filing limit from the date of service (DOS) is 180 days.

For all original claims and adjustments involving other third party payers, the timely filing limit from the date of

service (DOS) is 365 days.

Claims for persons who are retroactively determined eligible for Medicaid must be received no later than 180 days

after the date of eligibility determination or the date of service, whichever is later.

Claims that exceed the prescribed timely filing limit are denied.

o (NCPDP EC #81/Timely Filing Exceeded).

Providers should contact the OptumRx Technical Call Center at 1-866-244-8554 for late claim override

consideration.


3.0 PROGRAM REQUIREMENTS

3.1 DISPENSING LIMITS

Days’ Supply

There is a per claim day supply maximum of 34 days*.

*Drug Agents which allow up to 100 days’ supply

Anticonvulsants Thyroid Preparations

*Drug Agents which require 90-100 days after

one-time initial fill

Contraceptives, Topical Antiarrhythmics

Estrogens Progesterone

Contraceptives, Oral Antidiabetics

Antihypertensives Cardiac Glycosides

Antianginals Diuretics

If 80% of a non-controlled or 90% of a controlled medication has been utilized (the system will calculate

back to the original fill date) the system will automatically allow the claim to go through. If 80% of a non-

controlled or 90% of a controlled medication has not been used, the system will message back the next

date the prescription may be filled.

Dose/Duration

All claims are interrogated against the Preferred Drug List (PDL), benefit requirements and DUR criteria.

A complete listing of prior authorization criteria, step therapy requirements, quantity limits, and duration of

therapy edits can be found online through the DHCFP’s website (http://dhcfp.nv.gov).

All claims are interrogated for compliance with state and federal requirements.

Prescriptions must be dispensed pursuant to the orders of a physician or legally authorized prescriber.

Any subsequent refills may be dispensed not more than one year from the date the prescription was

written (or earlier whenever legally dictated).



Schedule II controlled substances (CIIs) may not be refilled; a new prescription is required for each fill.

Controlled drugs other than CIIs may be refilled, pursuant to the order of a physician or legally authorized

prescriber, up to five refills or six months, whichever comes first.

Non-controlled drugs may be refilled, pursuant to the order of a physician or legally authorized prescriber,

up to one year.

Oral Contraceptives

Oral contraceptives can be filled up to a 12-month supply after an initial 3-month supply followed by a 9-

month supply.

Subsequent prescriptions may continue to be filled for up to 12 months.

3.2 TAMPER-RESISTANT PRESCRIPTIONS

Medicaid is mandated by federal statute to require all written (non-electronic) prescriptions for all outpatient

drugs for Medicaid recipients to be on tamper-resistant prescription pads. This requirement does not apply to e-

prescriptions transmitted to the pharmacy, prescriptions faxed to the pharmacy or prescriptions communicated to the

pharmacy by telephone by a prescriber.

As of October 1, 2008, prescriptions are required to have a minimum of one feature from each of the three Centers

for Medicare & Medicaid Services (CMS) categories listed below:

1) Industry-recognized feature(s) designed to prevent unauthorized copying.

Feature Description

“Void” or “Illegal” pantograph

The word “Void” appears when the prescription is photocopied. Due to the word “Void” on faxed prescriptions, this feature requires the pharmacy to document if the prescription was faxed.

Watermarking Special paper containing “watermarking.”

2) Industry-recognized feature(s) designed to prevent erasure or modification written by the prescriber.

Feature Description

Quantity check off

boxes with refill

indicator (circle or

check number of

refills or “NR”)

In addition to the written quantity on the prescription, quantities are indicated in

ranges. It is recommended that ranges be 25’s with the highest being “151 and

over.” The range box corresponding to the quantity prescribed MUST be

checked for the prescription to be valid.

Indicates the number of refills on the prescription. Refill number must be used to

be a valid prescription. Document if the prescription was faxed.


Feature Description

Uniform non-white

background color

Background that consists of a solid color or consistent pattern that has been

printed onto the paper. This will inhibit a forger from physically erasing written or

printed information on a prescription form. If someone tries to erase or copy, the

consistent background color will look altered and show the color.

3) Industry-recognized feature(s) designed to prevent use of counterfeit prescription forms.

Feature Description

Security features and descriptions listed on

prescriptions

Complete list of the security features on the prescription

paper for compliance purposes.

Heat sensing imprint By touching the imprint or design, the imprint will

disappear.

NOTE: Be advised that all prescriptions paid for by Nevada Medicaid must follow these state/federal regulations.

3.3 E-PRESCRIBING

Nevada Medicaid encourages prescribers to submit electronic prescriptions. Recipient pharmacy claims history, eligibility,

drug coverage data and the indication of the need for a PA are also available to prescribers who use electronic

prescribing systems.

Prescribers who use electronic prescribing systems can arrange for appropriate access to this data by contacting their

software vendors.

For more information, see the Nevada Medicaid website www.medicaid.nv.gov and select E-prescribing from the

Provider’s menu.

3.4 DISPENSING PRACTITIONERS

Nevada Medicaid reimburses practitioners to dispense medications from a remote site or satellite consultation site when

the following criteria are met:

a. Must have a current Certificate of Registration through the Nevada State Board of Pharmacy. Refer to NRS

639.070 and NAC 639.390.

b. Must be enrolled with Nevada Medicaid provider enrollment as a provider type 28.

c. The dispensing practitioner’s site must be located in the State of Nevada.

d. All prior authorization criteria and quantity limitation apply to dispensing practitioner claims.

e. Only provider type 28 claims will receive a dispensing fee.

f. All claims must be submitted in the NCPDP format through Medicaid’s POS system.

http://www.medicaid.nv.gov/


3.5 GENERIC SUBSTITUTION POLICY

Per Nevada Revised Statute (NRS) 639.2583, if the practitioner has not indicated that generic substitution is prohibited,

the pharmacy provider must dispense, in substitution, another drug which is available to him if the other drug:

Is less expensive than the drug prescribed by brand name;

Is biologically equivalent to the drug prescribed by brand name;

Has the same active ingredient or ingredient of the same strength, quantity and form of dosage as

the drug prescribed by brand name; and

Is of the same generic type as the drug prescribed by brand name and the least expensive of the

drugs that are available to him for substitution.

Should a prescriber indicate that a branded drug is medically necessary for a recipient, the prescriber must comply with

the following:

The physician should document in the recipient’s medical record the need for the brand name

product in place of the generic form.

The certification must be in the physician’s own handwriting.

Certification must be written directly on the prescription blank.

The phrase “Dispense as written” is required on the face of the prescription. For electronically

transmitted prescriptions, “Dispense as written” must be noted. Not acceptable: a printed box on

the prescription blank checked by the prescriber to indicate “brand necessary” or a handwritten

statement transferred to a rubber stamp and then stamped on the prescription.

A prior authorization is required to override generic substitution.

Certification is not required if a generic is not manufactured.

A fax copy/verbal order may be taken by the pharmacist from the physician, but the pharmacy must

obtain an original printed copy and it keep on file.

3.6 MAXIMUM ALLOWABLE COST (MAC) LIST

State Maximum Allowable Costs is the upper reimbursement limit for multi-source outpatient

pharmaceuticals established by the DHCFP or Fiscal Agent.

The MAC List is updated monthly. Providers may access information regarding the OptumRx /Nevada

Medicaid Maximum Allowable Cost by viewing the following link:

https://www.medicaid.nv.gov/providers/rx/MACinfo.aspx.

https://www.medicaid.nv.gov/providers/rx/MACinfo.aspx


Providers who have questions or concerns about a particular MAC price may submit a MAC Price

Research Request Form, which can be found on the Nevada website:

https://www.medicaid.nv.gov/providers/rx/MACinfo.aspx.

Providers may appeal the current SMAC for pharmaceutical product if a provider determines that a

particular multi-source drug is not available at the current SMAC reimbursement.

The pharmacy must contact the Fiscal Agent technical call center to initiate the appeal.

Information needed to make the decision will include NDC number, manufacturer, drug name,

strength and price paid. A faxed copy of the actual invoice for the drug may be requested.

Inquiries not resolved by the technical call center are forwarded to the Fiscal Agent’s SMAC

Coordinator for investigation and resolution.

If it is determined the SMAC is negatively impacting access to care for recipients, the SMAC

Coordinator has the authority to 1) adjust SMAC pricing for the particular claim being appealed, and

2) make changes to the SMAC pricing file.

Appeals will be responded to within three working days of the referral to the SMAC Coordinator.

3.7 COVERED AND NON-COVERED DRUGS

The Nevada Medicaid Drug program will pay for medications as outlined in Medicaid Services Manual,

Chapter 1200:

Covered legend and non-legend pharmaceutical manufacturers must participate in the federal

Medicaid Drug Rebate Program unless listed on the excluded list in Chapter 1200 of the Medicaid

Services Manual.

Pharmaceuticals must be prescribed for a medically accepted indication.

Family planning items such as diaphragms, condoms, foams and jellies are a covered benefit.

The Nevada Medicaid Drug Rebate Program will not reimburse for the following pharmaceuticals:

Agents used for weight loss

Agents used to promote fertility

Agents used for cosmetic purposes or hair growth

Yohimbine

Drug Efficacy Study and Implementation (DESI) list “Less than Effective Drugs”

Pharmaceuticals considered “Experimental” as to substance or diagnosis for which prescribed.

Pharmaceuticals manufactured by companies not participating in the federal Medicaid Drug Rebate

Program unless rated “1-A” by the FDA.

Agents used for impotence/erectile dysfunction

3.8 COVERED OTC DRUGS

Over-the-counter medications are a covered Nevada Medicaid benefit subject to prior authorization:

Coverage is limited to two prescriptions per month within the same Standard Therapeutic Class (please see Appendix B of Chapter 1200 of the Medicaid Services Manual for a list of Standard

https://www.medicaid.nv.gov/providers/rx/MACinfo.aspx


Therapeutic Classes) without PA. Any more than two prescription requests for medications within the same therapeutic class will require PA.

Insulin will be exempt from any Clinical PA requirements.

3.9 RECIPIENT CO-PAY INFORMATION

Nevada Medicaid and Nevada Check Up do not require the recipient to pay a co-pay.

3.10 PRIOR AUTHORIZATION PROCEDURES AND DIAGNOSIS CODES

Technical Call Center

The OptumRx Technical Call Center (866) 244-8554 assists in the following circumstances on behalf of

Nevada Medicaid:

Early Refills (DUR Reject 79): The Technical Call Center may assist in overriding this reject if one of the

following circumstances exists:

Dosage/Therapy change has occurred; patient is no longer taking the original dosage

Dosage Time/Frequency Change has occurred

2 strengths of the same drug are used to make a strength of that medication not currently

manufactured

NOTE: At this time, no other exceptions will be made.

Clinical Call Center

The OptumRx Clinical Call Center (855) 455-3311 assists in the following authorization requests/overrides

on behalf of Nevada Medicaid:

Preferred Drug List (PDL) Therapeutic Duplication

Step Therapy Drug-Drug Interaction

Clinical Criteria All Other Clinical Edits

Dose Optimization Quantity Limits

To request prior authorization for the edits listed above, the prescribing physician or the prescribing physician’s agent

must call the OptumRx Clinical Call Center at (855) 455-3311. Prescribers may also initiate a prior authorization by faxing

the appropriate request form to (855) 455-3303. Should the pharmacist have access to the applicable clinical information,

they may initiate the prior authorization request.

OptumRx provides a Provider Portal for a physician or their agent to enter the required clinical information

required for a prior authorization decision. This portal gives an instant decision and is strongly suggested

as the first level of prior authorization processing. The portal may be accessed through

http://dhcfp.nv.gov

Ideally prior authorizations should be obtained at the time the prescription is being written. If this does not

occur, the claim is denied at POS with a message that the prescriber should contact (855) 455-3311 for

prior authorization consideration.



The OptumRx Clinical Call Center responds to all prior authorization requests within 24 hours of initiation.

o If more information is needed from the prescriber to make a determination for the prior

authorization, the physician has three business days to respond to any such request. After that,

the request will be denied.

It is not necessary to enter a PA number when the claim is transmitted. An active PA record in the

OptumRx system is all that is necessary.

Prior authorization edits apply to all claims.

Appropriate Diagnosis for Prior Authorization Bypass

In an effort to assist prescribers and providers, prior authorization requirements can be bypassed for certain medications

when specific medical conditions exist. Those specific medications and diagnoses are noted in the Nevada Medicaid

Services Manual, Chapter 1200. Prescribers are encouraged to include the applicable diagnosis code on written

prescriptions for inclusion on the electronic pharmacy claim. The submitted claim should include a Diagnosis Code

Qualifier (field 492-WE) of “01,” indicating ICD-10, as well as the appropriate Diagnosis Code (Field 424-DO).

3.11 THE PREFERRED DRUG LIST

Nevada Medicaid and Nevada Check Up utilize a Preferred Drug List (PDL). Non-preferred drugs in the listed classes

require prior authorization.

The PDL can be found on the Nevada Medicaid/OptumRx website https://www.medicaid.nv.gov/providers/rx/PDL.aspx.

Visit this website to ensure you have the most recent version of the PDL as it is updated periodically.

3.12 EMERGENCY SUPPLY POLICY

If the prescriber is not available and the pharmacist feels the recipient needs to receive the prescribed drug, the

pharmacist should contact the Clinical Call Center at: (855) 455-3311. OptumRx may authorize a 96-hour emergency

supply.

NOTE: An emergency situation is a situation that, in the judgment of the dispensing pharmacist, involves an

immediate threat of severe adverse consequences to the recipient, or the continuation of immediate and severe

adverse consequences to the recipient, if an outpatient drug is not dispensed when a prescription is submitted.

3.13 COORDINATION OF BENEFITS

It is important that providers be aware that Nevada Medicaid is always the payer of last resort, except as defined in

Medicaid Services Manual Chapter 100. Each Nevada Medicaid recipient should be asked whether he/she is covered by

any pharmacy insurance provider other than Medicaid. If the recipient identifies any other pharmacy payer(s), the

pharmacy is required to bill all other payers prior to billing pharmacy claims to Nevada Medicaid.

https://www.medicaid.nv.gov/providers/rx/PDL.aspx


As a matter of program policy, providers must bill all other payers first and then bill Nevada Medicaid.

Nevada Medicaid is always the payer of last resort.

If the recipient shows other coverage on the date of service (DOS), the pharmacy will receive a “41”

Reject Code — Submit to Primary Payer.

The pharmacy will also receive a message with information about the recipient’s TPL, including the PCN

(if applicable), BIN number, Identification Number, Group Number, and telephone number to the Nevada

Medicaid recipient’s primary insurance plan.

The pharmacy must then submit the claim to the primary insurance for payment.

If other payment is received, providers must resubmit the prescription claim to Nevada Medicaid with the

following information for payment consideration (see COB Reference Guide below and Payer

Specification Sheet in Section 7.0 for complete detailed situations):

OTHER COVERAGE CODE (NCPDP #308-C8) = only values of “2”, “3” or “4” in this field are

accepted

OTHER PAYER AMOUNT PAID field (NCPDP #431-DV) = amount received from all other payers

(must be greater than $0.00)

OTHER PAYER DATE (NCPDP #443-E8) = date payment received from other payer

In all cases, OptumRx uses the Nevada Medicaid “Allowed Amount” when calculating payment. If the

primary insurer has reimbursed greater than the Nevada Medicaid Allowed Amount, this may result in

zero payment on the secondary claim.

Nevada Medicaid Pharmacy Coordination of Benefits Requirements

NCPDP #308-C8

When to Use Submission Requirements / Responses

O- Not Specified

Allowed; submit when member does not have other health insurance. Submit Processed as Primary, reject 41 if TPL on member record

Claim will reject with a 41 error if member record has alternate insurance. Additional fields in the NCPDP COB segment should not be submitted with this OCC.

Claim should be sent to Primary Insurance and then resubmitted with proper OCC and other required fields.

1- No Other Coverage

Allowed; this code value indicates that they did attempt to determine if there was other coverage but weren’t able to find any

Claim will reject with a 41 error if member record has alternate insurance. Additional fields in the NCPDP COB segment should not be submitted with this OCC. Claim should be sent to Primary Insurance and then resubmitted with proper OCC and other required fields or call Clinical Call Center for 41 reject override.


2- Exists Payment Collected

OCC 2 is used when any positive amount of money is collected from another payer. Submit the amount collected from the primary payer (TPL), along with the date the claim was adjudicated to the primary payer (TPL) in order to override the TPL denial.

Paid claim; also requires submission of:

Other Payer Amount Paid (431-DV) that is > $0

Other Payer Amount Paid Qualifier (342-HC) that is valid

Patient Paid Amount Submitted (433-DX) this is => $0

Other Payer Date (443-E8) that is valid

Other Payer ID (340-7C) that is valid

Other Payer ID Qualifier (339-6C) that is valid

Claims submitted without proper required COB fields will reject with code 13.

3- Exists Claim Not Covered

OCC 3 is used when the Nevada Medicaid recipient has other primary insurance, but the particular drug is not covered by the specific plan(s).

Requires submission of: Other Payer Date (443-E8) Other Payer ID (340-7C) Other Payer ID Qualifier (339-6C)

And the reject code generated after billing the other insurer(s) in the “Other Payer Reject Code (472-6E). Claim will pay only if the following Other Payer Reject codes are submitted: 60, 61, 63, 65, 66, 67, 68, 69, 70, 3Y


4- Exists Payment Not Collected

OCC 4 is used when a recipient’s primary insurance plan is active, but there is no payment collected from the primary insurer because the beneficiary has not met their primary payer’s deductible obligation. This value should also be used if the total cost of the claim is less than the patient’s primary insurance co-pay requirement and the primary insurance plan made no payment.

Paid claim; also requires submission of :

Other Payer Amount Paid (431-DV) that = $0

Other Payer Amount Paid Qualifier (342-HC)

Patient Paid Amount Submitted (433-DX) this is > $0



Other Payer ID Qualifier (339-6C)


8- Claim Billing for a Copay

OCC 8 is used when billing a co-pay from Medicare Part D

Paid claim; also requires submission of:

Other Payer Amount Paid (431-DV) that is > $0

Other Payer Amount Paid Qualifier (342-HC) that is valid

Patient Paid Amount Submitted (433-DX) this is => $0




Other Payer ID Qualifier (339-6C) that is valid

Claim submitted without proper required COB fields will reject with NCPDP code 13.


3.14 MEDICARE PART D PLAN (PDP) AND DUAL-ELIGIBLE RECIPIENTS

Recipients eligible for both Medicare and Medicaid benefits (“dual-eligibles”) will receive prescription drug coverage

through a Medicare Part D Prescription Drug Plan (PDP).

All claims for dual-eligibles must be billed to the recipient’s Medicare PDP prior to billing Medicaid. Submit the claim to

Medicaid using standard COB processing, i.e., include all required COB processing fields.

Medicare Excluded Drugs

Some drugs are not covered by the Medicare PDP. Medicare excluded drug categories are:

OTC Medications

Cough and Cold Medications

Vitamin and Mineral Supplements including Prenatal Vitamins

Submit your claim to Medicaid after the Medicare PDP denies the claim as a non-covered benefit. Enter a “3” (Other

coverage exists, this claim not covered) in Field 308-C8 (Other Coverage Code).

Medicaid requires a prescription for all drugs, prescribed and OTC. All current Medicaid limitations and exclusions apply

to claims not covered by a recipients’ Medicare PDP.

Co-Payment Claims

Medicaid will cover prescription co-payments ($1.25 for generics, $3.70 for brands) for non-institutionalized dual-eligibles

who have an eligibility code of “A” or “B.”

Medicaid does not cover Medicare Part D co-pays ($2.40 for generics, $6.00 for brands) for dual-eligible recipients with an

eligibility code of “5” or “S.”

Medicaid will not reimburse Part D co-pays for recipients in Long-Term Care (LTC) facilities as these co-pays are waived

per federal Medicare regulations.

Medicaid will cover Medicare Part B co-pays for dual-eligible recipients with an eligibility code of “A,” “B,” “5” or “S.”

Medicaid co-pay logic does not allow for the reimbursement of a dual-eligible co-pay for an amount greater than $3.70.

For Medicare Part B covered drugs, the co-pay amount can and will exceed this amount in most cases. To exceed the

current $3.70 co-pay maximum for Part B covered drugs for recipients with Part B and D, bill Medicare Part B as the

primary payer. Medicaid can be billed as the secondary payer using standard COB billing practices. For Part B covered

drugs, enter the Other Coverage Code of "2" (Field 308- C8). The Gross Amount Due (Field 430-DU) should equal the

Medicare allowed amount.

Diabetic Supplies

Blood glucose testing equipment and supplies, as well as injection devices, are a Part B-covered benefit. These items are

not considered Part D drugs and therefore are not a Part D benefit. After billing Medicare Part B for these items, Medicaid

can be billed as the secondary payer using standard COB billing practices.

Enter the Other Coverage Code of "2" (Field 308- C8). The Gross Amount Due (Field 430-DU) should equal the Medicare

allowed amount. The Part D carrier code, 07450 (Field 340-7C) and Part B carrier code, 04967, are required for

processing diabetic supply claims for recipients that are eligible for Medicaid, Medicare Part D and Medicare Part B.


3.15 GENDER IDENTITY DISORDER HORMONES

Hormones used in the treatment of individuals with Gender Identity Disorder are a covered benefit for Nevada Medicaid

recipients. The prescription must document the proper diagnosis of F64.1 through F64.9 (Gender Identity Disorders).

The gender restriction will be bypassed when the pharmacy transmits this diagnosis on the electronic claim.

3.16 FAMILY PLANNING DRUGS

You may submit claims for family planning drugs directly to Medicaid without billing a primary insurance carrier first.

3.17 HOSPICE DRUGS

As stated in MSM Chapter 3200, drugs, supplies and durable medical equipment prescribed for conditions other than for

the palliative care and management of the terminal illness are not covered benefits under the Nevada Medicaid hospice

program and are to be billed in accordance with the appropriate Medicaid Services Manual chapter for those services.

Hospice recipients can be identified by:

Information on the recipient’s Medicaid enrollment file, or

The PATIENT LOCATION code (Field 307-C7) on the inbound claim contains a code “11” (Hospice)

To bill for a drug that is unrelated to the terminal illness, use override code “08” in Field 461-EU (Payer Defined

Exemption).

3.18 LONG-TERM CARE CLAIMS

Drugs that are generally included in the per diem rate are not a covered benefit. Refer to Medicaid

Services Manual Chapter 500 for complete information on LTC

Non-billable Items

o IV Hydration therapy of standard fluids without additives (e.g. antibiotics, potassium and heparin)

and supplies associated with I.V. therapy, enteral nutrition and TPN administration are part of the

LTC or Nursing Facility per diem rate and may not be billed as a separate charge. The following

items are not billable for recipients in an LTC facility (they are considered covered through the per

diem rate).

Dental supplies

Disposable supplies

Emollient supplies

Endocrine supplies

Fluid and electrolyte supplies


Metabolic, nutritional and temperature supplies

Respiratory supplies

Supplements (see MSM Chapter 1300)

Urological Supplies

Wound Care Supplies

Billable Items

o I.V. Drugs/TPN may be billed as a separate charge for recipients in LTC facilities

Unit Dose Repackaging Incentive

o An incentive plan is available to pharmacies who repackage non-unit dose products (tablets and

capsules) to recipients in a LTC facility. Email [email protected] for enrollment and

program details.

o Enrolled pharmacies are entitled to a per claim incentive fee of $0.43. Submit this fee in the

INCENTIVE AMOUNT SUBMITTED field (438-E3). Additionally, submit a value of “3” (Pharmacy

Unit Dose) in the UNIT DOSE INDICATOR field (Field 429-DT)

o In addition, nursing facilities must properly credit the Medicaid program for the return of unused

prescription medicines upon discontinuance of the prescription or transfer, discharge or death of

a Medicaid beneficiary. This is to assure there is no double billing of medications.

Drugs Indicated as Unit Dose: As indicated by Medispan, most unit dose drugs are covered for recipients

in LTC facilities only. If a medication is ONLY available as in unit dose packaging, coverage will also be

included for non-LTC recipients.

Please note: Patients who reside in “Assisted Living Facilities” are not considered as “Long-Term Care” patients.

Identify claims for recipients in a LTC facility by entering “04” (Long Term/Extended Care) in Field 307-C7 (Patient Location)

3.19 340B DRUG DISCOUNT PROGRAM

The 340B Drug Discount Program is a federal program that requires drug manufacturers to provide covered outpatient

drugs to certain eligible 340B-enrolled entities at significantly reduced prices. For these 340B entities, the Division of

Health Care Financing and Policy (DHCFP) is prohibited from claiming drug rebates as this would subject the drug

manufacturers to duplicative discounts. All drug claims submitted by a 340B pharmacy to DHCFP are excluded from the

drug rebate collection process.

DHCFP utilizes the Health Resources and Services Administration’s (HRSA’s) Medicaid Exclusion File to identify 340B

providers. Pharmacies registered as a 340B pharmacy must bill with their actual acquisition cost. If a pharmacy decides to

bill DHCFP as a 340B pharmacy, ALL outpatient drugs billed to DHCFP must be billed with the pharmacy’s actual

acquisition cost. This applies to Medicaid Fee-for-Service and Medicaid Managed Care claims.

Please refer to: http://www.hrsa.gov/opa/ for more details.

mailto:[email protected]

http://www.hrsa.gov/opa/


3.20 SPECIAL RECIPIENT CONDITIONS (“LOCKED-IN” PATIENTS)

When a recipient shows patterns of abuse/misuse of benefits, the recipient can be “Locked In” to a pharmacy.

Patients may be locked into a designated pharmacy. Pharmacies will receive a NCPDP-50 reject if they try to fill a prescription from an unauthorized pharmacy. In the event of an emergency, OptumRx may be contacted for override consideration.

Any Nevada Medicaid participating pharmacy has the right to accept or decline any “locked-in” Nevada

Medicaid recipient only after contacting the OptumRx Technical Help Desk at 1-866-244-8554.

3.21 COMPOUNDS

A $10.17 dispensing fee applies to all compound claims.

Compound Claims Processing

All compounds must be submitted using the NCPDP version D.0 standard multi-ingredient compound

functionality. Therefore, all ingredients must be identified, their units must be indicated, and the ingredient

cost for each ingredient must be submitted on the claim. At least one item in the compound must be a

covered drug. If an excluded or non-PDL agent is included in the compound, the claim will reject for

“invalid compound.” The pharmacy may place an “8” in the submission clarification code field and

resubmit the claim; however, be advised that any component of a compound requiring prior authorization

will necessitate an approval prior to receiving payment from The Nevada Medicaid Pharmacy Program.

Provider Instructions

There are three segments that must be completed to submit a compound claim. Nevada Medicaid is listing

the required entries by NCPDP field numbers. If you are unsure where these specific fields are located in

your software please contact your software provider and give them the full Payer Specification Sheet for

the Nevada Medicaid Pharmacy program that is included in this manual under Appendix B. P

On Claim Segment:

o Enter PRODUCT CODE/NDC (NCPDP Field # 407-D7) as “00000000000” on the claim segment to

identify the claim as a multi-ingredient compound.

o Enter COMPOUND CODE (NCPDP Field # 406-D6) of “2.”

o Enter QUANTITY DISPENSED (NCPDP Field # 442-E7) for the entire product.

o Enter INGREDIENT DRUG COST (NCPDP Field # 409-D9) of the entire product.

This must equal the sum of the individual ingredient drug costs submitted in the compound

segment.

o Enter GROSS AMOUNT DUE (NCPDP Field # 430-DU) for the entire product.

o Enter USUAL AND CUSTOMARY CHARGE (NCPDP Field # 426-DQ) for entire product.

o SUBMISSION CLARIFICATION CODE (NCPDP Field # 420-DK) = 8 (Process Compound for

Approved Ingredients) allows a claim to continue processing if at least one ingredient is covered. This

is only needed if the compound contains a non-covered ingredient (see section 3.14 above).


On Compound Segment:

o COMPOUND DISPENSING UNIT FORM INDICATOR (NCPDP Field # 451-EG)

Acceptable values are ML or GM

o COMPOUND ROUTE OF ADMINISTRATION (NCPDP Field # 452-EH)

Example values are:

1) 3 = Inhalation

2) 4 = Injection

3) 11 = Oral

4) 13 = Otic

5) 15 = Rectal

6) 17 = Topical

o COMPOUND INGREDIENT COMPONENT COUNT (NCPDP Field # 447- EC) - must equal the

number of NDCs transmitted in the compound segment (Maximum of 25)

o For each line item (ingredient):

COMPOUND PRODUCT ID QUALIFIER (NCPDP Field # 488-RE), always 03 = NDC

COMPOUND PRODUCT ID (NCPDP Field # 489-TE), NDC of ingredient

COMPOUND INGREDIENT QUANTITY (NCPDP Field # 448-ED), quantity of the individual

ingredient included in the compound

COMPOUND INGREDIENT DRUG COST (NCPDP Field # 449-EE), cost of the individual ingredient

included in the compound

Important Notes

The Claim Segment Product ID (i.e., NDC) is defined as a mandatory field and, therefore, must be submitted for all claims, including multi-ingredient compounds.

A non-blank space value is expected in the Claim Segment Product ID field for field validation. The

pharmacy submits all zeroes in this field for a multi-ingredient compound. For compound segment

transactions, the claim is rejected if all zeroes are not submitted as the Product ID.

A Submission Clarification Code value of “8” only allows a claim to continue processing if at least one

ingredient is covered. Non-rebateable ingredients will process with the submission clarification code; but

only rebateable ingredients are eligible for reimbursement.

Each multi-ingredient compound claim counts as one claim towards the Brand Rx fill limits, if applicable.

Pharmacies must transmit the same NDC numbers that are being used to dispense the medication.

Compounds which contain an antibiotic must also contain another active ingredient. For example, an

antibiotic suspension plus flavoring or an injectable antibiotic plus a fluid will not be covered as a

compound.

Coverage of Active Pharmaceutical Ingredients (APIs)

o An API is defined by 21 C.F.R. § 207.3(a)(4) as a bulk drug substance that “is represented for

use in a drug and that, when used in the manufacturing, processing, or packaging of a drug,

becomes an active ingredient or a finished dosage form of the drug.” APIs may be included in

extemporaneously compounded prescriptions and may serve as the active drug component in a

compounded formulation.


3.22 PARTIAL FILL FUNCTIONALITY

Partial fill functionality allows pharmacies to bill for partial quantities of a single prescription. The following rules apply:

Partial fills must be billed via the POS system

The dispensing fee is prorated according to the quantity dispensed

Partial fill functionality cannot be used with multi-ingredient compound claims

Partial fills may not be transferred from one pharmacy to another

You may not submit two partial fill transactions for the same prescription on the same day; the service

date must be different for each partial fill.

The following sections list the NCPDP fields that are required to submit initial, subsequent and final claims using the

partial fill functionality.

Initial Claims – complete these fields on an initial partial fill claim.

• Quantity Dispensed (Field 442-E7): Enter the actual quantity dispensed for this claim

• Days Supply (Field 405-D5): Enter the number of days supply that was dispensed for this

claim

• Dispensing Status (Field 343-HD): Enter “P” in this field

• Quantity Intended to be dispensed (Field 344-HF): Enter the total quantity that was

prescribed

• Days Supply Intended to be dispensed (Field 345-HG): Enter the total days supply that was

prescribed

Subsequent Claims – Complete these fields on a subsequent partial fill claim

• Associated Prescription/Service Reference Number (Field 456-EN): Enter the prescription

number from the initial partial fill

• Associated Prescription/Service Date (Field 457-EP): Enter the date of service of the most

recent partial fill in the series.

• Quantity Dispensed (Field 442-E7): Enter the actual quantity dispensed for this claim.

• Days Supply (Field 405-D5): Enter the number of days supply that was dispensed.

• Dispensing Status (Field 343-HD): Enter “P” in this field.

• Quantity Intended to be Dispensed (Field 344-HF): Enter the total quantity that was

prescribed.

• Days Supply Intended to be Dispensed (Field 345-HG): Enter the total days supply that was

prescribed.

Final Claim – Complete these fields on a final partial fill claim:

• Associated Prescription/Service Reference Number (Field 456-EN): Enter the prescription

number from the initial partial fill

• Associated Prescription/Service Date (Field 457-EP): Enter the date of service of the most

recent partial fill in the series.

• Quantity Dispensed (Field 442-E7): Enter the actual quantity dispensed for this claim.

• Days Supply (Field 405-D5): Enter the number of days supply dispensed

• Dispensing Status (Field 343-HD): Enter “C” in this field

• Quantity Intended to be Dispensed (Field 344-HF): Enter the total quantity that was

prescribed

• Days Supply Intended to be Dispensed (Field 345-HG): Enter the total days supply that was

prescribed


3.23 INJECTABLE DRUGS

Intravenous (I.V.) therapy drugs claims must be submitted through the pharmacy POS system using the Multi-Ingredient

Functionality.

Dispensing Fees:

• For outpatient antibiotic therapy, a daily dispensing fee of $10.17 will be applied to the claim.

• For recipients in Long-Term Care, a daily dispensing fee of $.10.17 will be applied to the claim. This fee

will be multiplied by the number of days the therapy was provided.

Supplies

• I.V. therapy supplies, enteral nutrition/supplies, Standard Total Parenteral Nutrition (TPN) solution and

supplies are billed on CMS-1500 claim form or through the 837P electronic transaction. Medications

added to TPN Solution immediately prior to administration are billed through the pharmacy POS system.

• For coverage and limitations, see the Billing Guidelines for Provider Type 33, MSM Chapter 1200,

Section 1203.2 and MSM Chapter 1300.

3.24 REFILLS

Dispense refills pursuant to the orders of the physician, but not more than one year from the date of the original

prescription.

Early refills may be dispensed only when 80% of the prescription is used for non-controlled drugs and 90% for controlled

drugs. Recipients must use drugs in accordance with the prescriber’s orders.

3.25 VACATION FILL

To override an Early Refill denial message for a non-controlled substance (Reject Code 88) where the prescriber has

authorized a vacation fill, enter ‘03’ as the Submission Clarification Code (Field 420-DK).

3.26 REASON FOR SERVICE CODE (CONFLICT CODE)

A Reason for Service Code (Reject Code E4) defines the type of utilization conflict that was detected (Field 439).

Professional Service codes and Result of Service codes are required for Severity Level One Conflict codes.

3.27 LOST MEDICATION

The recipient is responsible for payment to replace lost, stolen or otherwise destroyed medication even if a physician

writes a new prescription for the drug. Prior authorization may be granted in a life-threatening situation for maintenance

medication (refer to MSM Chapter 1200).

http://dhcfp.nv.gov/Resources/AdminSupport/Manuals/MSMDetail/

http://dhcfp.nv.gov/Resources/AdminSupport/Manuals/MSMDetail/


3.28 USE OF PHARMACY DRUG DISCOUNT CARDS BY RECIPIENTS AND RETRO-ELIGIBLE

REFUNDS

Per Nevada Medicaid’s Billing Manual for Nevada Medicaid and Nevada Check Up, any payment collected from a Nevada Medicaid recipient for a covered service must be returned to the recipient if they are later determined eligible for retroactive coverage that includes those dates of service. Nevada Check Up does not offer retroactive coverage. Nevada Medicaid offers up to three months of retroactive eligibility from the date in which the individual filed their application for assistance.

Drug discount cards can cause reimbursement issues for Medicaid recipients. If a recipient is pending Medicaid or becomes retro-eligible and has used a drug discount card for a drug claim, the transaction must be cancelled by the drug discount card processor in order to bill Medicaid. Pharmacies will be unable to bill Medicaid and reimburse the recipient until the initial claim using the discount drug card has been reversed. Online reversal of the claim may not be possible due to retail pharmacy company policies and system limitations. Manual reversal of the claim may or may not be possible; therefore, reimbursement cannot be guaranteed.

Pharmacies are encouraged to notify recipients using drug discount cards of this policy regarding future refunds.

4.0 PROSPECTIVE DRUG UTILIZATION REVIEW (PRODUR)

Prospective Drug Utilization Review (ProDUR) encompasses the detection, evaluation, and counseling components of

pre-dispensing drug therapy screening. The ProDUR system assists the pharmacist in these functions by addressing

situations in which potential drug problems may exist. ProDUR performed prior to dispensing helps pharmacists ensure

that their patients receive appropriate medications. This is accomplished by providing information to the dispensing

pharmacist that may not have been previously available. Because the ProDUR solution through OptumRx examines

claims from all participating pharmacies, drugs which interact or are affected by previously dispensed medications can be

detected. ProDUR edits can detect the following potential problems: therapeutic duplication, early refills, high dose, drug-

drug interactions, drug-inferred diagnosis interactions, drug-gender edits, and geriatric or pediatric precautions.

OptumRx recognizes that the pharmacist uses his/her education and professional judgment in all aspects of dispensing.

ProDUR is offered as an informational tool to aid the pharmacist in performing his/her professional duties. If a pharmacist

assesses a potential drug therapy problem, and determines that the prescription should be dispensed, the pharmacist can

override the ProDUR edit at point of sale using Pharmacy Professional Service (PPS) Codes (See table below).

Exceptions include ProDUR edits involving: narcotic analgesics, sedative hypnotics, benzodiazepines or skeletal muscle

relaxants. ProDUR edits for these four classes require a call to the call center in order to obtain an override.

Pharmacy Professional Service Codes

Response Field Response Codes

Conflict Code DD

HD

TD

DC

LD

MN

MX

PA

Drug-Drug Interaction

High Dose

Therapeutic Duplication

Drug-Disease

Low Dose

Insufficient Duration

Excessive Duration

Drug-Age

https://www.medicaid.nv.gov/Downloads/provider/NV_Billing_General.pdf


Intervention Code M0

P0

R0

Prescriber consulted

Patient consulted

Pharmacist consulted other source

Outcome Code 1A

1B

1C

1D

1E

1G

Filled As Is, False Positive

Filled Prescription As IS

Filled, With Different Dose

Filled, With Different Directions

Filled, With Different Quantity

Filled, With Prescriber Approval

4.1 THERAPEUTIC AND CLINICAL EDITS

Therapeutic Duplication

A Therapeutic Duplication edit has been enabled for specific therapeutic classes as a safety precaution. Claims

encountering this edit are denied with an NCPDP “88” Reject - TD. Additional information is shared as outlined in Section

4.3 below.

Therapeutic Duplication Alert Classes*

ACE Inhibitors Antipsychotics H2RAs

ACE Inhibitors/CCB Benzodiazepines (Anxiety) Leukotrienes

Alpha Blockers Benzodiazepines (Insomnia) Statins (lipotropics)

Angiotensin Receptor

Blockers Beta Blockers Fibrates (lipotropics)

Antiarthritics (NSAIDS, COX-

II) Bile Salt Sequestrants Narcotic Analgesics

Antidepressants (SSRI,

SNRI) Calcium Channel Blockers Quinolones

Antidepressants (TCAs) PPIs Skeletal Muscle Relaxants

Antihistamines

*The above list may not be all inclusive and is subject to change


4.2 CALL CENTERS

The OptumRx Technical Call Center is available 24 hours per day, seven days a week. The telephone number is

(866) 244-8554. Alert message information is available from the Technical Call Center after the message appears. If you

need assistance with any alert or denial messages, it is important to contact the Technical Call Center about ProDUR

messages at the time of dispensing. The Technical Call Center can provide claims information on all error messages,

which are sent by the ProDUR system. This information includes: NDCs and drug names of the affected drugs, dates of

service, whether the calling pharmacy is the dispensing pharmacy of the conflicting drug, and days supply.

The Technical Call Center is not intended to be used as a clinical consulting service and cannot replace or supplement the

professional judgment of the dispensing pharmacist. OptumRx has used reasonable care to accurately compile ProDUR

information. Because each clinical situation is unique, this information is intended for pharmacists to use at their own

discretion in the drug therapy management of their patients.

A second level of assistance is available if a provider’s question requires a clinical response. To address these situations,

OptumRx clinical pharmacists are available for consultation and are located at the Clinical Call Center. The telephone

number is (855) 455-3303. The Clinical Call Center is available 24 hours a day, seven days a week.

4.3 PRODUR ALERT/ERROR MESSAGES

ProDUR is an integral part of the Nevada Medicaid Pharmacy Program’s claims adjudication process. ProDUR includes:

reviewing claims for therapeutic appropriateness before the medication is dispensed; reviewing the available medical

history; focusing on those patients at the highest severity of risk for harmful outcome; and intervening and/or counseling

when appropriate.

All ProDUR alert messages appear at the end of the claims adjudication transmission. Alerts appear in the following

format:

Format Field Definitions

Reason for Service Up to three characters. Code transmitted to pharmacy when a conflict

is detected (e.g., ER, HR, TD, DD).

Severity Index Code One character. Code indicates how critical a given conflict is.

Other Pharmacy Indicator One character. Indicates if the dispensing provider also dispensed

the first drug in question.

1 = Your Pharmacy

3 = Other Pharmacy

Previous Date of Fill Eight characters. Indicates previous fill date of conflicting drug in

YYYY/MM/DD format.

Quantity of Previous Fill Five characters. Indicates quantity of conflicting drug previously

dispensed.

Database Indicator One character. Indicates source of ProDUR message.

1 = First Data Bank

4 = Processor Developed

Other Prescriber One character. Indicates the prescriber of conflicting prescription.

0 = No Value

1 = Same Prescriber

2 = Other Prescriber


5.0 PROVIDER REIMBURSEMENT

5.1 SWITCHING FEES

OptumRx does NOT charge any switching fees for any claims. Pharmacies may be charged switching fees by

their individual “claims switching service.” Pharmacies are encouraged to consult with their claims switching

service for further details.

5.2 AMBULATORY/LTC NETWORK PHARMACY PAYMENT ALGORITHMS

Pricing for all drugs and supplies (except diabetic, family planning supplies and immunizations) is always the “lesser of”:

• National Average Drug Acquisition Cost (NADAC) + Dispensing Fee

• Wholesale Acquisition Cost (WAC) + Dispensing Fee

• Federal Upper Limit (FUL) + Dispensing Fee

• Maximum Allowable Cost (MAC) + Dispensing Fee

• Department of Justice (DOJ) – 15% + Dispensing Fee

• Gross Amount Due (Field 430-DU) (Submitted)

• Usual and Customary (Field 425-DQ) (Submitted)

• Actual Acquisition Cost (AAC) (Submitted)

Pricing for Diabetic and Family Planning Supplies is always the “Lesser of”:

• Wholesale Acquisition Cost (WAC) + 8% + $1.54 Dispensing Fee

• Gross Amount Due (Field 430-DU)

• Usual and Customary (Field 425-DQ)

Actual Acquisition Cost (AAC)

For products that do not have WAC, FUL, MAC or DOJ pricing on file, a pharmacy will be prompted to submit their actual

acquisition price. The pharmacy should submit the actual invoiced cost of the medication for the quantity submitted.

The Point of Sale system will return the message “PLEASE SUBMIT PHARMACY ACQUISITION PRICE AND SUBMIT

PRIOR AUTH #00000000012” if no other pricing is on file for the submitted NDC. The pharmacy should submit the

following:

The calculated actual acquisition cost in the “Gross Amount Due” (430-DU) field

The “PA Type Code” (461-EU) field should be “1”

The “PA Number Submitted” (462-EV) field should be “00000000012”

Compounds (Other than Home I.V. antibiotics)

Each individual ingredient is priced as above + the applicable dispense fee. The lesser of calculated amount, Usual

and Customary, and Gross Amount Due are reimbursed. There are no additional repackaging fees.


5.3 AMBULATORY/LTC NETWORK PHARMACY DISPENSING FEES

Dispensing fee is currently $10.17 per claim.

5.4 PHARMACIST ADMINISTERED IMMUNIZATIONS

Effective April 17, 2012, Nevada Medicaid and Nevada Check Up will reimburse pharmacies for administering

adult and childhood immunizations.

Requirements

The administering pharmacist must be appropriately certified by the Nevada State Board of Pharmacy.

Records must be kept on file for auditing.

Pharmacies are responsible for physician oversight of the program and other state licensing requirements per

Nevada Board of Pharmacy Rules.

Pharmacies must enter immunization given in the Nevada WebIZ Website.

Pharmacies must enroll in the Vaccines for Children Program (VFC). VFC vaccines are provided by the Nevada

State Health Division for recipients who are under 19 years of age at no cost to the provider.

The following is a list of covered immunizations:

Covered Vaccines

Influenza

Tetanus, diphtheria, pertussis (Td/Tdap)

Varicella

HPV (Male and Female) (Provided through VFC program through age 18)

Zoster (only covered for recipients 50 years old and greater, not included in VFC)

Measles, Mumps, Rubella (MMR)

Pneumococcal

Meningococcal

Hepatitis A

Hepatitis B

Inactivated Poliovirus

Haemophilus influenza type b

Rotavirus

Reimbursement

The administration fee is $7.80 if administered in the pharmacy. If dispensed and administered off site,

the pharmacy will be reimbursed the standard dispensing fee.

All claims should be submitted through the Pharmacy Point of Sale System.

Pharmacies will not be reimbursed an ingredient cost for VFC Program Immunization, but pharmacies will

receive the administration fee.

Ingredient cost will be reimbursed using the lesser-of logic payment algorithm.


Claims Submission for Pharmacist Administered Immunizations

For POS claims:

o Submit ingredient cost submitted (409-D9)

o Submit Dispensing Fee Submitted (412-DC)

o Submit Patient Paid Amount (433-DX)

o It is not required, but Incentive Amount (433-E3) may be submitted

o Submit Gross Amount Due (430-DU)

o All other fields are the same as standard POS claims.

Response for POS claims:

o You will only be reimbursed what is allowed according the payment algorithm.

o If the recipient is 18 years old or less, a zero ingredient cost (506-F6) will be returned, if the recipient is 19

years old or over, the ingredient cost will be reimbursed based on the algorithm above.

o The administration fee will be returned in the Incentive Fee field (521-FL) for all claims for immunizations.

Billing Instructions for Vaccine Claims when Submitted with a Non-participating Prescriber Due to Ordering,

Prescribing and Referring (OPR) Practitioner Validation

Effective February 6, 2015, pharmacies submitting claims for vaccines to Nevada Medicaid and Nevada Check Up with non-participating prescribers will need to enter the following information:

Prior Authorization Type (461-EU) = ‘01’

Prior Authorization Number Submitted (462-EV) = ‘44444444444’

This override is applicable only when billing for vaccines.

For more information:

Visit: http://dpbh.nv.gov/Programs/Programs or http://dpbh.nv.gov/Programs/VFC/VFC_-_Home for information specific

for Vaccine for Children (VFC).

All vaccines administered must be documented in Nevada’s WebIZ – the Statewide Immunization Information System.

Please visit: http://dpbh.nv.gov/Programs/WebIZ/WebIZ_-_Home for enrollment information.

6.0 PROVIDER EDUCATION

Provider Educators are available to assist Nevada Medicaid providers who may have questions regarding the

pharmacy program (i.e., Preferred Drug List (PDL), Point-of-sale messaging, etc).

In addition to ensuring PDL compliance, the overall objective for provider educators is to improve provider

awareness of the Nevada Medicaid pharmacy program policies and procedures.

Regular training sessions are held via teleconference throughout the year. Please refer to the Pharmacy

Announcements/Training webpage at https://www.medicaid.nv.gov for dates and times.

E-mail [email protected] or call (775) 335-8537 to request training or ask questions.

http://dpbh.nv.gov/Programs/Programs

http://dpbh.nv.gov/Programs/VFC/VFC_-_Home

http://dpbh.nv.gov/Programs/WebIZ/WebIZ_-_Home


mailto:[email protected]


7.0 APPENDICES TO THIS MANUAL

Appendix A – Instructions for Completing the NCPDP Universal Claim Form (Ver 5.1)

Appendix B – NCPDP D.O Payer Sheet for Pharmacy Providers

Appendix C – Other Carrier Code List

Appendix D – Quantity Limits (If more than the listed quantity is needed for treatment, please call the OptumRx Clinical Call Center for a prior authorization: (855) 455-3303.)

Appendix E – Drugs Not Requiring Whole Quantities (Partial units may be billed to allow the remaining quantity to be administered to another recipient instead of wasted. This applies to outpatient retail claims billed through point of sale (POS) and physician administered drugs (PAD).)

OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer

health products. We are an Optum® company – a leading provider of integrated health services. Learn more at

optum.com.

All Optum® trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks or

registered marks of their respective owners.

https://www.medicaid.nv.gov/Downloads/provider/NV_BillingGuidelines_PT28_A.pdf

https://www.medicaid.nv.gov/Downloads/provider/NV_BillingGuidelines_PT28_B.pdf

https://www.medicaid.nv.gov/Downloads/provider/NV_BillingGuidelines_PT28_C.pdf

https://www.medicaid.nv.gov/Downloads/provider/NV_BillingGuidelines_PT28_C.pdf

https://www.medicaid.nv.gov/Downloads/provider/NV_BillingGuidelines_PT28_D.pdf

https://www.medicaid.nv.gov/Downloads/provider/NV_BillingGuidelines_PT28_E.pdf

Documents

NV Medicaid and NV Check Up Pharmacy Manual€¦ · CHECK UP PHARMACY MANUAL Effective February 23, 2018 . Updated: 02/23/2018 (pv02/20/2018) Page 2 of 31 ... NV Medicaid and NV Check